There are many ways in which rural America has fallen behind the rest of the country. The health care gap, however, has the potential for the most tragic consequences.
Rural America has higher rates of suicide, obesity and alcohol abuse. People who live there have a lower life expectancy and are more likely to die of potentially preventable causes like stroke, cancer and heart disease. Exacerbating these problems, only 10 percent of the country's doctors practice in rural areas. Finding mental health care is even harder -- 61 percent of rural Americans live in a federally-designated Mental Health Professional Shortage Area.
The Trump administration wants to close these gaps and hopes to do it by easing the regulations on rural providers.
Earlier this month, the Centers for Medicare and Medicaid Services (CMS) released a vague rural health plan that vows to, among other things, advance telehealth and improve access to care through "provider engagement." But the most important line in the eight-page document, according to rural health advocates, says the federal government will “apply a rural lens to CMS programs and policies.”
“That’s the most significant thing because that’s been the biggest issue for the past couple of decades,” says Alan Morgan, CEO of the National Rural Health Association. "The [feds] release a regulation, and nobody asked ‘what’s that going to mean for rural [areas]?'"
This is the first time, according to Morgan, that CMS has said it will formally and consistently take into consideration how federal policies impact the nation's smallest clinics and hospitals.
More often than not, rural health advocates say health care regulations -- however well-intentioned -- are burdensome because hospitals and clinics often can't afford to make the required changes. Some of the regulations from the Affordable Care Act, for example, are cited as part of the reason that 83 rural hospitals have closed since 2010.
In the last months of the Obama administration, CMS also finalized a rule meant to address the doctor shortage in rural America. It requires states to set a maximum time and distance that people have to wait or travel for a doctor's appointment.
“How does a state like Nevada write such a standard when most people live in one area?” said Maggie Elehwany, government affairs and policy vice president for the National Rural Health Association, in a 2016 interview. "We know what CMS is trying to do, so we’re happy about it because there is such a workforce shortage. But it is really hard right now to see what states are going to do."
Rural health providers have also criticized an Obama-era rule called “exclusive use,” which mandates that a specialist, like a cardiologist or dermatologist, have a separate waiting area from the rest of a clinic. If not, Medicaid will consider them clinic care instead of outpatient care, and the specialist receives less Medicaid funding.
In rural clinics and hospitals, where resources are usually more limited, that rule has led many places to spend money on renovations.
“We just remodeled so we were in compliance, but not every place can do that. That would have been devastating to lose that outpatient reimbursement,” says Leslie Marsh, CEO of the Lexington Regional Medical Center in Nebraska.
Morgan hopes more flexibility will keep them from having to continually change their health centers to "solve urban health care problems."
It remains to be seen, though, how examining regulations through a "rural lens" is going to change policies. But Morgan says he will know if it does.
“How will I know if a rule was passed without giving a thought to rural? Oh we’ll know. If it’s not something that can be carried out in a small clinic or hospital, we’ll know."
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